# Client intake & health history

**Confidential client record — do not store completed copies in this GitHub repository or send them through an unsecured form or email.** Keep only information needed for safe coaching, restrict access, and establish a retention/deletion policy.

> **Trainer note:** This custom intake is not a substitute for a recognized pre-participation screening tool. Before starting exercise, have the client complete the current official [PAR-Q+](https://parqplus.org/) and follow its direction for follow-up or medical clearance. ACE recommends collecting health history, exercise history, goals, and informed consent before training. Do not diagnose or provide medical treatment.

## Client details

- Full name:
- Preferred name:
- Date of birth (confirm adult client, 18+):
- Phone:
- Email:
- Preferred way/time to contact:
- Emergency contact name and relationship:
- Emergency contact phone:
- Date completed:
- Trainer:

## Goals and preferences

1. What would you like to work toward in training?
2. Why is this important to you now?
3. What would progress look or feel like to you?
4. What kinds of activity do you enjoy? What would you rather avoid?
5. How many days per week can you realistically train?
6. What equipment and space do you have available?
7. Do you prefer in-person, Zoom, or a mix?
8. Is there anything that would help me make sessions more comfortable or accessible for you?

## Exercise and activity history

- Current weekly activity and typical duration:
- Previous or current strength training experience:
- Exercises or activities you particularly like/dislike:
- Recent changes in activity, energy, or exercise tolerance:
- Relevant sports, work, or daily movement demands:

## Health and safety discussion

Please complete the current official PAR-Q+ separately and discuss any concern it raises with the appropriate health professional. Do not put detailed medical records here.

- Is there anything about your health that may affect exercise today? ☐ No ☐ Yes — discuss privately with trainer
- Have you been advised to restrict, modify, or avoid exercise? ☐ No ☐ Yes — discuss privately; provide written clearance if indicated
- Do you currently have pain, dizziness, unusual shortness of breath, or another symptom during activity? ☐ No ☐ Yes — pause training and seek appropriate medical guidance
- Is there an accommodation or modification you want me to know about? ☐ No ☐ Yes — discuss privately
- Other safety information the client chooses to share:

## Session logistics

- Training location / address (if in-person):
- Access, parking, pets, stairs, or other setup notes:
- For Zoom: device, camera angle, available space and equipment:
- Preferred days/times:
- Any scheduling constraints:

## Acknowledgment

I have answered these questions honestly to the best of my knowledge. I understand this information helps the trainer plan exercise but does not constitute a medical evaluation. I will tell the trainer about relevant changes before a session and stop exercise if I experience concerning symptoms.

Client signature: ______________________________ Date: ______________

Trainer reviewed PAR-Q+ and any follow-up needed: ______________________________ Date: ______________

**Store completed client records securely and separately from this public website source repository.**